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Geng Y, Liu J, Yin X, Zhao R, Zhu L. Reconstruction for extensive sacrococcygeal defects in complex tumor patients with personalized customized gluteus maximus myocutaneous flaps. J Tissue Viability 2024:S0965-206X(24)00132-3. [PMID: 39242280 DOI: 10.1016/j.jtv.2024.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 08/17/2024] [Accepted: 08/23/2024] [Indexed: 09/09/2024]
Abstract
AIM To evaluate the clinical effects of personalized customized gluteus maximus myocutaneous flaps (GMMF) for reconstruction of extensive sacrococcygeal soft tissue defects in complex tumor patients. METHODS A retrospective chart review was conducted on 8 patients who underwent personalized customized GMMF reconstruction for large sacrococcygeal defect from December 2021 to August 2023. The personalized customized GMMF were designed based on the variations of tissue defect in location, shape and volume of different dead spaces. The principle of the personalized GMMF is to ensure that the rotation point of the flap can reach the farthest end of the defect. Patient demographics, operative characteristics, and perioperative risk factors were analyzed. Clinical outcomes were assessed, focusing on complications such as flap necrosis, wound dehiscence, infection, seroma, and hematoma. RESULTS Six patients with rectal cancer and two with sacral tumors underwent personalized customized GMMF reconstruction for extensive sacrococcygeal defects. The average volume of the wound cavity was 104 mL, with a mean vertical depth was 10.8 cm. Six patients had low serum albumin (<35 g/L). After a mean follow-up of 15.5 months, no major complications occurred, except for one seroma that resolved within 2 weeks. CONCLUSION The personalized customized GMMF described in this study is an effective method for reconstructing large sacrococcygeal wounds with significant depth in complex tumor patients. It allows for greater rotation of the muscle flap into the sacrococcygeal wound defect and provides adequate blood supply by utilizing the bulk of muscle tissue to obliterate dead space.
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Affiliation(s)
- Yingnan Geng
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, China
| | - Jinyue Liu
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, China
| | - Xiaolin Yin
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, China
| | - Rongxin Zhao
- Department of Dermatology, Pudong New Area People's Hospital, 490 Chuanhuan South Road, Pudong New Area, Shanghai, China
| | - Lie Zhu
- Department of Burns and Plastic Surgery, Second Affiliated Hospital of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, China.
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Rotaru V, Chitoran E, Zob DL, Ionescu SO, Aisa G, Andra-Delia P, Serban D, Stefan DC, Simion L. Pelvic Exenteration in Advanced, Recurrent or Synchronous Cancers-Last Resort or Therapeutic Option? Diagnostics (Basel) 2024; 14:1707. [PMID: 39202196 PMCID: PMC11353817 DOI: 10.3390/diagnostics14161707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/29/2024] [Accepted: 08/05/2024] [Indexed: 09/03/2024] Open
Abstract
First described some 80 years ago, pelvic exenteration remain controversial interventions with variable results and ever-changing indications. The previous studies are not homogenous and have different inclusion criteria (different populations and different disease characteristics) and methodologies (including evaluation of results), making it extremely difficult to properly assess the role of pelvic exenteration in cancer treatment. This study aims to describe the indications of pelvic exenterations, the main prognostic factors of oncologic results, and the possible complications of the intervention. Methods: For this purpose, we conducted a retrospective study of 132 patients who underwent various forms of pelvic exenterations in the Institute of Oncology "Prof. Dr. Al. Trestioreanu" in Bucharest, Romania, between 2013 and 2022, collecting sociodemographic data, characteristics of patients, information on the disease treated, data about the surgical procedure, complications, additional cancer treatments, and oncologic results. Results: The study cohort consists of gynecological, colorectal, and urinary bladder malignancies (one hundred twenty-seven patients) and five patients with complex fistulas between pelvic organs. An R0 resection was possible in 76.38% of cases, while on the rest, positive margins on resection specimens were observed. The early morbidity was 40.63% and the mortality was 2.72%. Long-term outcomes included an overall survival of 43.7 months and a median recurrence-free survival of 24.3 months. The most important determinants of OS are completeness of resection, the colorectal origin of tumor, and the presence/absence of lymphovascular invasion. Conclusions: Although still associated with high morbidity rates, pelvic exenterations can deliver important improvements in oncological outcomes in the long-term and should be considered on a case-by-case basis. A good selection of patients and an experienced surgical team can facilitate optimal risks/benefits.
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Affiliation(s)
- Vlad Rotaru
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Elena Chitoran
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Daniela-Luminita Zob
- Medical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Sinziana-Octavia Ionescu
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Gelal Aisa
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Prie Andra-Delia
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
| | - Dragos Serban
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Surgery Department 4, Bucharest University Emergency Hospital, 050098 Bucharest, Romania
| | - Daniela-Cristina Stefan
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Laurentiu Simion
- Medicine School, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- General Surgery and Surgical Oncology Department I, Bucharest Institute of Oncology “Prof. Dr. Al. Trestioreanu”, 022328 Bucharest, Romania
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Khan JS, Piozzi GN, Rouanet P, Saklani A, Ozben V, Neary P, Coyne P, Kim SH, Garcia-Aguilar J. Robotic beyond total mesorectal excision for locally advanced rectal cancers: Perioperative and oncological outcomes from a multicentre case series. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108308. [PMID: 38583214 DOI: 10.1016/j.ejso.2024.108308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/14/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Around 20% of rectal tumors are locally advanced with invasion into adjacent structures at presentation. These may require surgical resections beyond boundaries of total mesorectal excision (bTME) for radicality. Robotic bTME is under investigation. This study reports perioperative and oncological outcomes of robotic bTME for locally advanced rectal cancers. MATERIALS AND METHODS A multicentre, retrospective analysis of prospectively collected robotic bTME resections (July 2015-November 2020). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. RESULTS One-hundred-sixty-eight patients (eight centres) were included. Median age and BMI were 60.0 (50.0-68.7) years and 24.0 (24.4-27.7) kg/m2. Female sex was prevalent (n = 95, 56.8%). Fifty patients (29.6%) were ASA III-IV. Neoadjuvant chemoradiotherapy was given to 125 (74.4%) patients. Median operative time was 314.0 (260.0-450.0) minutes. Median estimated blood loss was 150.0 (27.5-500.0) ml. Conversion to laparotomy was seen in 4.8%. Postoperative complications occurred in 77 (45.8%) patients; 27.3% and 3.9% were Clavien-Dindo III and IV, respectively. Thirty-day mortality was 1.2% (n = 2). R0 rate was 92.9%. Adjuvant chemotherapy was offered to 72 (42.9%) patients. Median follow-up was 34.0 (10.0-65.7) months. Distant and local recurrences were seen in 35 (20.8%) and 15 patients (8.9%), respectively. Overall survival (OS) at 1, 3, and 5-years was 91.7, 82.1, and 76.8%. Disease-free survival (DFS) at 1, 3, and 5-years was 84.0, 74.5, and 69.2%. CONCLUSION Robotic bTME is technically safe with relatively low conversion rate, good OS, and acceptable DFS in the hands of experienced surgeons in high volume centres. In selected cases robotic approach allows for high R0 rates during bTME.
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Affiliation(s)
- Jim S Khan
- Department of Colorectal Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; University of Portsmouth, Portsmouth, UK.
| | | | - Philippe Rouanet
- Department of Surgery, Institut Régional du Cancer de Montpellier, Montpellier Cancer Research Institute, University of Montpellier, Montpellier, France.
| | - Avanish Saklani
- Division of Colorectal Oncology, Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India.
| | - Volkan Ozben
- Department of General Surgery, Acibadem Mehmet Ali Aydinlar University, School of Medicine, Acibadem Atakent Hospital, Istanbul, Turkey.
| | - Paul Neary
- Division of Colorectal Surgery, The Adelaide and Meath Hospital Ireland, Dublin, Ireland.
| | - Peter Coyne
- Department of Colorectal Surgery, Royal Victoria Infirmary, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK.
| | - Seon Hahn Kim
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA.
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Milanko NA, Kelly ME, Turner G, Kong J, Behrenbruch C, Mohan H, Guerra G, Warrier S, McCormick J, Heriot A. Evaluating postoperative hernia incidence and risk factors following pelvic exenteration. Int J Colorectal Dis 2024; 39:70. [PMID: 38717479 PMCID: PMC11078832 DOI: 10.1007/s00384-024-04638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/12/2024]
Abstract
Pelvic exenteration (PE) is a technically challenging surgical procedure. More recently, quality of life and survivorship following PEs are being increasingly acknowledged as important patient outcomes. This includes evaluating major long-term complications such as hernias, defined as the protrusion of internal organs through a facial defect (The PelvEx Collaborative in Br J Surg 109:1251-1263, 2022), for which there is currently limited literature. The aim of this paper is to ascertain the incidence and risk factors for postoperative hernia formation among our PE cohort managed at a quaternary centre. METHOD A retrospective cohort study examining hernia formation following PE for locally advanced rectal carcinoma and locally recurrent rectal carcinoma between June 2010 and August 2022 at a quaternary cancer centre was performed. Baseline data evaluating patient characteristics, surgical techniques and outcomes was collated among a PE cohort of 243 patients. Postoperative hernia incidence was evaluated via independent radiological screening and clinical examination. RESULTS A total of 79 patients (32.5%) were identified as having developed a hernia. Expectantly, those undergoing flap reconstruction had a lower incidence of postoperative hernias. Of the 79 patients who developed postoperative hernias, 16.5% reported symptoms with the most common symptom reported being pain. Reintervention was required in 18 patients (23%), all of which were operative. CONCLUSION This study found over one-third of PE patients developed a hernia postoperatively. This paper highlights the importance of careful perioperative planning and optimization of patients to minimize morbidity.
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Affiliation(s)
- Nicole Anais Milanko
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
| | - Michael Eamon Kelly
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Trinity St James Cancer Institute, Dublin, Ireland
| | - Greg Turner
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Auckland District Health Board, Auckland, New Zealand
| | - Joeseph Kong
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Cori Behrenbruch
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Helen Mohan
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Glen Guerra
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Satish Warrier
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
| | - Jacob McCormick
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia
- Department of General Surgery, Royal Melbourne Hospital, Melbourne, Australia
| | - Alexander Heriot
- Peter MacCallum Comprehensive Cancer Centre, Department of Surgical Oncology with the University of Melbourne, Melbourne, Australia.
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Li Y, Zhuang M, Hu G, Zhang J, Qiu W, Mei S, Tang J. A novel classification of posterior pelvic exenteration to assess prognosis in female patients with locally advanced primary rectal cancer: a retrospective cohort study from China PelvEx collaborative. Int J Colorectal Dis 2024; 39:59. [PMID: 38664256 PMCID: PMC11045567 DOI: 10.1007/s00384-024-04632-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
PURPOSE Surgical techniques and the prognosis of posterior pelvic exenteration for locally advanced primary rectal cancer in female patients pose challenges that need to be addressed. Therefore, we investigated the short-term and survival outcomes of posterior pelvic exenteration in female patients using a novel Peking classification. METHODS We retrospectively analysed a prospective database from China PelvEx Collaborative across three tertiary referral centres. A total of 172 patients who underwent combined resection for locally advanced primary rectal cancer were classified based on four subtypes (PPE-I [64/172], PPE-II [68/172], PPE-III [21/172], and PPE-IV [19/172]) according to the Peking classification; perioperative characteristics and short-term and oncological outcomes were analysed. RESULTS Differences were significant among the four groups regarding colorectal reconstruction (p < 0.001), perineal reconstruction (p < 0.001), in-hospital complications (p < 0.05), and urinary retention (p < 0.05). The R0 resection rates for PPE-I, PPE-II, PPE-III, and PPE-IV were 90.6%, 89.7%, 90.5%, and 89.5%, respectively. The 5-year overall survival rates of the PPE-I, PPE-II, PPE-III, and PPE-IV groups were 73.4%, 68.8%, 54.7%, and 37.3%, respectively. Correspondingly, their 5-year disease-free survival rates were 76.0%, 62.5%, 57.7%, and 43.1%, respectively. Notably, the PPE-IV group demonstrated the lowest 5-year overall survival rate (p < 0.001) and 5-year disease-free survival rate (p < 0.001). CONCLUSION The Peking classification can aid in determining suitable surgical techniques and conducting prognostic assessments in female patients with locally advanced primary rectal cancer.
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Affiliation(s)
- Yuegang Li
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Meng Zhuang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Gang Hu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jinzhu Zhang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Wenlong Qiu
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Shiwen Mei
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jianqiang Tang
- Department of Colorectal Surgery, National Clinical Research Center for Cancer/Cancer Hospital, National Cancer Center, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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Maudsley J, Clifford RE, Aziz O, Sutton PA. A systematic review of oncosurgical and quality of life outcomes following pelvic exenteration for locally advanced and recurrent rectal cancer. Ann R Coll Surg Engl 2024. [PMID: 38362800 DOI: 10.1308/rcsann.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Pelvic exenteration (PE) is now the standard of care for locally advanced (LARC) and locally recurrent (LRRC) rectal cancer. Reports of the significant short-term morbidity and survival advantage conferred by R0 resection are well established. However, longer-term outcomes are rarely addressed. This systematic review focuses on long-term oncosurgical and quality of life (QoL) outcomes following PE for rectal cancer. METHODS A systematic review of the PubMed®, Cochrane Library, MEDLINE® and Embase® databases was conducted, in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Studies were included if they reported long-term outcomes following PE for LARC or LRRC. Studies with fewer than 20 patients were excluded. FINDINGS A total of 25 papers reported outcomes for 5,489 patients. Of these, 4,744 underwent PE for LARC (57.5%) or LRRC (42.5%). R0 resection rates ranged from 23.2% to 98.4% and from 14.9% to 77.8% respectively. The overall morbidity rates were 17.8-87.0%. The median survival ranged from 12.5 to 140.0 months. None of these studies reported functional outcomes and only four studies reported QoL outcomes. Numerous different metrics and timepoints were utilised, with QoL scores frequently returning to baseline by 12 months. CONCLUSIONS This review demonstrates that PE is safe, with a good prospect of R0 resection and acceptable mortality rates in selected patients. Morbidity rates remain high, highlighting the importance of shared decision making with patients. Longer-term oncological outcomes as well as QoL and functional outcomes need to be addressed in future studies. Development of a core outcomes set would facilitate better reporting in this complex and challenging patient group.
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Affiliation(s)
- J Maudsley
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, UK
- Division of Cancer Sciences, University of Manchester, UK
| | - R E Clifford
- Institute of Translational Medicine, University of Liverpool, UK
| | - O Aziz
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, UK
- Division of Cancer Sciences, University of Manchester, UK
| | - P A Sutton
- Colorectal and Peritoneal Oncology Centre, Christie NHS Foundation Trust, UK
- Division of Cancer Sciences, University of Manchester, UK
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van Rees JM, Nordkamp S, Harmsen PW, Rutten H, Burger JWA, Verhoef C. Locally recurrent rectal cancer and distant metastases: is there still a chance ofcure? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106865. [PMID: 37002176 DOI: 10.1016/j.ejso.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/23/2023] [Accepted: 03/03/2023] [Indexed: 03/13/2023]
Abstract
INTRODUCTION Patients with locally recurrent rectal cancer (LRRC) generally have poor prognosis, especially those who have (a history of) distant metastases. The aim of this study was to investigate the impact of distant metastases on oncological outcomes in LRRC patients undergoing curative treatment. METHODS Consecutive patients with surgically treated LRRC between 2005 and 2019 in two tertiary referral hospitals were retrospectively analysed. Oncological survival of patients without distant metastases were compared with outcomes of patients with synchronous distant metastases with the primary tumour, patients with distant metastases in the primary-recurrence interval, and patients with synchronous LRRC distant metastases. RESULTS A total of 535 LRRC patients were analysed, of whom 398 (74%) had no (history of) metastases, 22 (4%) had synchronous metastases with the primary tumour, 44 (8%) had metachronous metastases, and 71 (13%) had synchronous LRRC metastases. Patients with synchronous LRRC metastases had worse survival compared to patients without metastases (adjusted hazard ratio: 1.56 [1.15-2.12]), whilst survival of patients with synchronous primary metastases and metachronous metastases of the primary tumour was similar as those patients who had no metastases. In LRRC patients who had metastases in primary-recurrence interval, patients with early metachronous metastases had better disease-free survival as patients with late metachronous metastases (3-year disease-free survival: 48% vs 22%, p = 0.039). CONCLUSION LRRC patients with synchronous distant metastases undergoing curative surgery have relatively poor prognosis. However, LRRC patients with a history of distant metastases diagnosed nearby the primary tumour have comparable (oncological) survival as LRRC patients without distant metastases.
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Affiliation(s)
- J M van Rees
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands.
| | - S Nordkamp
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - P W Harmsen
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - H Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands; GROW: School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - J W A Burger
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - C Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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Bedrikovetski S, Traeger L, Jay AA, Oehler MK, Cho J, Wagstaff M, Vather R, Sammour T. Is preoperative sarcopenia associated with postoperative complications after pelvic exenteration surgery? Langenbecks Arch Surg 2023; 408:173. [PMID: 37133529 PMCID: PMC10156810 DOI: 10.1007/s00423-023-02913-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/26/2023] [Indexed: 05/04/2023]
Abstract
PURPOSE Pelvic exenteration (PE) involves radical surgical resection of pelvic organs and is associated with considerable morbidity. Sarcopenia is recognised as a predictor of poor surgical outcomes. This study aimed to determine if preoperative sarcopenia is associated with postoperative complications after PE surgery. METHODS This retrospective study included patients who underwent PE with an available preoperative CT scan between May 2008 and November 2022 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia. Total Psoas Area Index (TPAI) was estimated by measuring the cross-sectional area of the psoas muscles at the level of the third lumbar vertebra on abdominal CT, normalised for patient height. Sarcopenia was diagnosed based on gender-specific TPAI cut-off values. Logistic regression analyses were performed to identify risk factors for major postoperative complications with a Clavien-Dindo (CD) grade ≥ 3. RESULTS In total, 128 patients who underwent PE were included, 90 of whom formed the non-sarcopenic group (NSG) and 38 the sarcopenic group (SG). Major postoperative complications (CD grade ≥ 3) occurred in 26 (20.3%) patients. There was no detectable association with sarcopenia and an increased risk of major postoperative complications. Preoperative hypoalbuminemia (P = 0.01) and a prolonged operative time (P = 0.002) were significantly associated with a major postoperative complication on multivariate analysis. CONCLUSION Sarcopenia is not a predictor of major postoperative complications in patients undergoing PE surgery. Further efforts aimed specifically at optimising preoperative nutrition may be warranted.
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Affiliation(s)
- Sergei Bedrikovetski
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia.
| | - Luke Traeger
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia
| | - Alice A Jay
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia
| | - Martin K Oehler
- Department of Gynaecological Oncology, Royal Adelaide Hospital, Adelaide, SA, 5000, Australia
- Centre for Cancer Biology, University of South Australia, Adelaide, South Australia, Australia
| | - Jonathan Cho
- Discipline of Obstetrics and Gynaecology, Adelaide Medical School, Robinson Research Institute, The University of Adelaide, Adelaide, SA, 5005, Australia
| | - Marcus Wagstaff
- Urology Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ryash Vather
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia
- Department of Plastic and Reconstructive Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Discipline of Surgery, Faculty of Health and Medical Sciences, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, 5E 332, Port Road, Adelaide, South Australia, 5000, Australia
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Takagawa Y, Suzuki M, Yamaguchi H, Seto I, Azami Y, Machida M, Takayama K, Tominaga T, Murakami M. Outcomes and Prognostic Factors for Locally Recurrent Rectal Cancer Treated With Proton Beam Therapy. Adv Radiat Oncol 2023; 8:101192. [PMID: 36896217 PMCID: PMC9991532 DOI: 10.1016/j.adro.2023.101192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 01/29/2023] [Indexed: 02/09/2023] Open
Abstract
Purpose Our objective was to report the outcome and prognostic factors for patients with locally recurrent rectal cancer (LRRC) treated with proton beam therapy (PBT) at our institution. Methods and Materials The study included PBT-treated patients with LRRC between December 2008 and December 2019. Treatment response was stratified using an initial imaging test after PBT. Overall survival (OS), progression-free survival (PFS), and local control (LC) were estimated using the Kaplan-Meier method. Each outcome's prognostic factors were verified using the Cox proportional hazards model. Results Twenty-three patients were enrolled (median follow-up, 37.4 months). There were 11 patients with complete response (CR) or complete metabolic response (CMR), 8 with partial response or partial metabolic response, 2 with stable disease or stable metabolic response, and 2 with progressive disease or progressive metabolic disease. Three- and 5-year OS, PFS, and LC were 72.1% and 44.6%, 37.9% and 37.9%, and 55.0% and 47.2%, respectively, with 54.4 months' median survival time. The maximum standardized uptake value of fluorine-18-fluorodeoxyglucose-positron emission tomography-computed tomography (18F-FDG-PET/CT) before PBT (cutoff value, 10) showed significant differences in OS (P = .03), PFS (P = .027), and LC (P = .012). The patients who achieved CR or CMR after PBT had significantly better LC than those with non-CR or non-CMR (hazard ratio, 4.49; 95% confidence interval, 1.14-17.63; P = .021). Older patients (aged ≥65 years) had significantly higher LC and PFS rates. Patients with pain before PBT and larger tumors (≥30 mm) also had significantly lower PFS. Of 23 patients, 12 (52%) experienced further local recurrence after PBT. One patient developed grade 2 acute radiation dermatitis. Regarding late toxicity, grade 4 late gastrointestinal toxic effects were recorded in 3 patients, in 2 of whom reirradiation was associated with further local recurrence after PBT. Conclusions The results showed that PBT may have potential to be a good treatment option for LRRC. 18F-FDG-PET/CT before and after PBT may be useful for assessing tumor response and predicting outcomes.
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Affiliation(s)
- Yoshiaki Takagawa
- Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
- Corresponding author: Yoshiaki Takagawa, MD
| | - Motohisa Suzuki
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Hisashi Yamaguchi
- Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Ichiro Seto
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Yusuke Azami
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Masanori Machida
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Kanako Takayama
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Takuya Tominaga
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
| | - Masao Murakami
- Department of Radiation Oncology, Southern TOHOKU Proton Therapy Center, Fukushima, Japan
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Carvalho F, Qiu S, Panagi V, Hardy K, Tutcher H, Machado M, Silva F, Dinen C, Lane C, Jonroy A, Knox J, Worley L, Whibley J, Perren T, Thain J, McPhail J. Total Pelvic Exenteration surgery - Considerations for healthcare professionals. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:225-236. [PMID: 36030135 DOI: 10.1016/j.ejso.2022.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/22/2022] [Accepted: 08/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Associated with considerable risk of morbidity, Total Pelvic Exenteration (TPE) is a life-altering procedure involving a significant prolonged recovery. As a result, and with the view of achieving the best outcomes and lessen short and long-term morbidities, a well-thought-out and coordinated multidisciplinary team approach, is crucial to the provision of safe and high-quality care. METHOD Using a nominal group technique and qualitative methodology, this article explores the current practices in the care of oncology patients who undergo TPE surgery, in a tertiary cancer centre, by highlighting considerations of a collaboratively multi-disciplinary team. RESULTS This article provides guidance on the multi-disciplinary team approach, relating to TPE surgery, with discussion of clinical concerns, and with the goal of high patient satisfaction, provision of effective care and the lessening of short and long-term morbidities. CONCLUSION Oncology patients that undergo TPE surgery benefit from the contribution of a diversified multidisciplinary team as skilled and competent care that meets patient's health and social care needs is provided in a holistic, comprehensive, and timely care manner. Improving patient's care, pathway and postoperative outcomes, with the use of clinical expertise and support from professionals in the multidisciplinary team, can maximise care.
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Affiliation(s)
- Filipe Carvalho
- The Royal Marsden Hospital NHS Foundation Trust, London, UK.
| | - Shengyang Qiu
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Vasia Panagi
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Katy Hardy
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Hannah Tutcher
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Marta Machado
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | | | - Caroline Dinen
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Carol Lane
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Alleh Jonroy
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Jon Knox
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Lynn Worley
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | | | - Tobias Perren
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - Jane Thain
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
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11
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Murata Y, Uehara K, Ogura A, Ishigaki S, Aiba T, Mizuno T, Kokuryo T, Yokoyama Y, Yatsuya H, Ebata T. Impact of combined resection of the internal iliac artery on loss of volume of the gluteus muscles after pelvic exenteration. Surg Today 2022:10.1007/s00595-022-02635-z. [DOI: 10.1007/s00595-022-02635-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/07/2022] [Indexed: 12/24/2022]
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12
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Fahy MR, Hayes C, Kelly ME, Winter DC. Updated systematic review of the approach to pelvic exenteration for locally advanced primary rectal cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2284-2291. [PMID: 35031157 DOI: 10.1016/j.ejso.2021.12.471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/23/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer. BACKGROUND The management of rectal cancer has evolved significantly in recent decades, with improved (neo)adjuvant treatment strategies and enhanced perioperative protocols. Centralization of care for complex, advanced cases has enabled surgeons in these units to undertake more ambitious surgical procedures. METHODS A Pubmed, Ovid, Embase and Cochrane database search was conducted according to the predetermined search strategy. The review protocol was prospectively registered with PROSPERO (CRD42021245582). RESULTS 14 studies were identified which reported on the outcomes of 3,188 patients who underwent pelvic exenteration (PE) for primary rectal cancer. 50% of patients had neoadjuvant radiotherapy. 24.2% underwent flap reconstruction, 9.4% required a bony resection and 34 patients underwent a major vascular excision. 73.9% achieved R0 resection, with 33.1% experiencing a major complication. Median length of hospital stay ranged from 13 to 19 days. 1.6% of patients died within 30 days of their operation. Five-year overall survival (OS) rates ranged 29%-78%. LIMITATIONS The studies included in our review were mostly single-centre observational studies published prior to the introduction of modern neoadjuvant treatment regimens. It was not possible to perform a meta-analysis on the basis that most were non-randomized, non-comparative studies. CONCLUSIONS Pelvic exenteration offers patients with locally advanced rectal cancer the chance of long-term survival with acceptable levels of morbidity. Increased experience facilitates more radical procedures, with the introduction of new platforms and/or reconstructive options.
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Affiliation(s)
- Matthew R Fahy
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland.
| | - Cathal Hayes
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Michael E Kelly
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
| | - Desmond C Winter
- Centre for Graduate Research, University College Dublin, Belfield, Dublin, 4, Ireland; Centre for Colorectal Disease, St. Vincent's University Hospital, Elm Park, Dublin, 4, Ireland
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13
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Traeger L, Bedrikovetski S, Oehler MK, Cho J, Wagstaff M, Harbison J, Lewis M, Vather R, Sammour T. Short-term outcomes following development of a dedicated pelvic exenteration service in a tertiary centre. ANZ J Surg 2022; 92:2620-2627. [PMID: 35866328 PMCID: PMC9795898 DOI: 10.1111/ans.17921] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/05/2022] [Accepted: 07/08/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pelvic exenteration surgery (PE) offers potentially curative resection for locally advanced malignancy but is associated with significant complexity and morbidity. Specialised teams are recommended to achieve optimal patient outcomes. This study aims to analyse short-term outcomes at a tertiary setting before and after creating a dedicated PE service. METHODS Patients undergoing PE between 2008 and October 2021 at the Royal Adelaide Hospital and St. Andrews Hospital in South Australia were included, with prospective data collection since June 2017. Patients operated on prior and post the creation of the PE service were compared via univariate analyses. RESULTS In total, 113 patients were included, with a significant increase in volume of cases post creation of the PE service, (n = 46 pre versus n = 67 post). There were significant differences in the type of neoadjuvant therapy and patient co-morbidity, with more advanced disease stage and a higher likelihood of bone involvement (P < 0.05) in the latter period. An increased proportion of patients had flap reconstruction (40.3 versus 33.9%, P = 0.010) as well as lateral lymph node dissection (13.4 versus 2.2%, P = 0.046). Despite this, peri-operative outcomes such as urosepsis (11.9 versus 28.3%, P = 0.028) and Clavien-Dindo grade of complications grade improved. R0 resections were achieved in 93.9% of curative cases (93.9 versus 84.2%, P = 0.171). CONCLUSION The development of a PE service significantly improved short term patient outcomes, despite the inclusion of patients with more advanced disease and comorbidity.
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Affiliation(s)
- Luke Traeger
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Sergei Bedrikovetski
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Martin K. Oehler
- Department of Gynaecological OncologyRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jonathan Cho
- Urology Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Marcus Wagstaff
- Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia,Department of Plastic and Reconstructive SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Jack Harbison
- Department of Plastic and Reconstructive SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Mark Lewis
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Ryash Vather
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
| | - Tarik Sammour
- Colorectal Unit, Department of SurgeryRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia,Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSouth AustraliaAustralia
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14
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Image-guided pelvic exenteration-preoperative and intraoperative strategies. Eur J Surg Oncol 2022; 48:2263-2276. [DOI: 10.1016/j.ejso.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 07/19/2022] [Accepted: 08/01/2022] [Indexed: 12/19/2022] Open
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15
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Sacroperineal Reconstruction With Inferior Gluteal Artery Perforator Flaps After Resection of Locally Advanced Primary and Recurrent Anorectal Malignancy. Ann Plast Surg 2022; 89:306-311. [PMID: 35993686 DOI: 10.1097/sap.0000000000003258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Modern interdisciplinary concepts with involvement of various surgical specialties can considerably reduce perioperative morbidity after sacroperineal resection of locally advanced primary or recurrent anorectal malignancies. Resultant defects can represent a major challenge for reconstruction particularly with chemoradiotherapy. The aim is to assess the long-term outcomes of sacroperineal reconstruction using inferior gluteal artery perforator flaps.We performed a retrospective data analysis on 31 patients who were treated with inferior gluteal artery perforator flaps (n = 61) over the period 2009-2021. The demographic data, comorbidities, operative details, and outcomes with special focus on wound infection and dehiscence were recorded.The median age was 42 year (range, 25-82 years) with preponderance of males (n = 21). The follow-up period ranged from 6 to 80 months. Early minor complications included superficial wound dehiscence (3), which was managed conservatively, whereas the major (2) included deep wound collection and infection (1), which required surgical drainage, and perineal hernia, which required repair. All flaps survived completely.Inferior gluteal artery perforator flaps are safe, robust, and reliable with less donor side morbidity and positive impact on quality of life. It should be considered as a valuable tool in the reconstructive armamentarium of sacroperineal defects within a multidisciplinary setting.
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16
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Gould LE, Pring ET, Drami I, Moorghen M, Naghibi M, Jenkins JT, Steele CW, Roxburgh CS. A systematic review of the pathological determinants of outcome following resection by pelvic exenteration of locally advanced and locally recurrent rectal cancer. Int J Surg 2022; 104:106738. [PMID: 35781038 DOI: 10.1016/j.ijsu.2022.106738] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/07/2022] [Accepted: 06/16/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Despite multimodal therapy 5-15% of patients who undergo resection for advanced rectal cancer (LARC) will develop local recurrence. Management of locally recurrent rectal cancer (LRRC) presents a significant therapeutic challenge and even with modern exenterative surgery, 5-year survival rates are poor at 25-50%. High rates of local and systemic recurrence in this cohort are reflective of the likely biological aggressiveness of these tumour types. This review aims to appraise the current literature identifying pathological factors associated with survival and tumour recurrence in patients undergoing exenterative surgery. METHODS A systematic review was carried out searching MEDLINE, EMBASE and COCHRANE Trials database for all studies assessing pathological factors influencing survival following pelvic exenteration for LARC or LRRC from 2010 to July 2021 following PRISMA guidelines. Risk of bias was assessed using QUIPS tool. RESULTS Nine cohort studies met inclusion criteria, reporting outcomes for 2864 patients. Meta-analysis was not possible due to significant heterogeneity of reported outcomes. Resection margin status and nodal disease were the most commonly reported factors. A positive resection margin was demonstrated to be a negative prognostic marker in six studies. Involved lymph nodes and lymphovascular invasion also appear to be negative prognostic markers with tumour stage to be of lesser importance. No studies assessed other adverse tumour features that would not otherwise be included in a standard histopathology report. CONCLUSION Pathological resection margin status is widely demonstrated to influence disease free and overall survival following pelvic exenteration for rectal cancer. With increasing R0 rates, other adverse tumour features must be explored to help elucidate differences in survival and potentially guide tailored oncological treatment.
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Affiliation(s)
- Laura E Gould
- University of Glasgow College of Medical Veterinary and Life Sciences, Academic Unit of Surgery, School of Medicine, United Kingdom; St Mark's Academic Institute, St Mark's Hospital, United Kingdom.
| | - Edward T Pring
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom; Imperial College London, United Kingdom
| | - Ioanna Drami
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom; Imperial College London, United Kingdom
| | - Morgan Moorghen
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom
| | - Mani Naghibi
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom
| | - John T Jenkins
- St Mark's Academic Institute, St Mark's Hospital, United Kingdom; Imperial College London, United Kingdom
| | - Colin W Steele
- University of Glasgow College of Medical Veterinary and Life Sciences, Academic Unit of Surgery, School of Medicine, United Kingdom
| | - Campbell Sd Roxburgh
- University of Glasgow College of Medical Veterinary and Life Sciences, Academic Unit of Surgery, School of Medicine, United Kingdom
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17
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Kitakaze M, Uemura M, Kobayashi Y, Paku M, Miyo M, Takahashi Y, Miyake M, Kato T, Ikeda M, Fujino S, Ogino T, Miyoshi N, Takahashi H, Yamamoto H, Mizushima T, Sekimoto M, Doki Y, Eguchi H. Postoperative pain management after concomitant sacrectomy for locally recurrent rectal cancer. Surg Today 2022; 52:1599-1606. [PMID: 35661260 DOI: 10.1007/s00595-022-02522-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/22/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess pain management in patients post-sacrectomy, focusing on opioid use, and to identify the factors associated with postoperative pain. METHODS Patients who underwent resection of locally recurrent rectal cancer (LRRC) with concomitant sacrectomy at one of two hospitals between 2007 and 2020 were reviewed retrospectively. We examined the use of opioids preoperatively and postoperatively. Patients were classified into high and low sacrectomy groups based on the sacral bone resection level passing through the S3 vertebra. RESULTS Sixty-four patients were enrolled. Opioid use was significantly higher in the high sacrectomy group than in the low sacrectomy group at all times assessed: on postoperative days 7, 14, 30, 90, 180, and 365. Opioid use 3 months after locally recurrent rectal cancer surgery was significantly higher in patients with local re-recurrence of the tumor than in those without re-recurrence (p < 0.05), and the median morphine-equivalent opioid use 3 months postoperatively was significantly higher in the high sacrectomy group (30 vs. 0 mg/day; p < 0.05). CONCLUSIONS Opioid use after concomitant sacrectomy for LRRC was higher in the high sacrectomy group. Prolonged postoperative pain or increasing pain was associated with local recurrence.
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Affiliation(s)
- Masatoshi Kitakaze
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Mamoru Uemura
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan.
| | - Yuta Kobayashi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Masakatsu Paku
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Masaaki Miyo
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Yusuke Takahashi
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Masakazu Miyake
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Takeshi Kato
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, 5400006, Japan
| | - Masataka Ikeda
- Division of Lower GI Surgery, Department of Surgery, Hyogo College of Medicine, Hyogo, 6638501, Japan
| | - Shiki Fujino
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Takayuki Ogino
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Norikatsu Miyoshi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Mitsugu Sekimoto
- Department of Surgery, Kansai Medical University, Osaka, 5731010, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Osaka University, 2-2 (E2) Yamadaoka, Suita, Osaka, 5650871, Japan
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18
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Yang H, Rui Y, Chen H. Management of a Pelvic Abscess and Abdominal Fistula after Palliative Total Pelvic Exenteration with Intraoperative Radiotherapy in Recurrent Rectal Cancer Without NPWT: A Case Report. Adv Skin Wound Care 2021; 34:675-679. [PMID: 34807899 PMCID: PMC8612897 DOI: 10.1097/01.asw.0000797964.31949.b4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
ABSTRACT A 59-year-old man with recurrent rectal cancer and type 2 diabetes mellitus underwent palliative total pelvic exenteration and intraoperative radiotherapy. After surgery, he experienced a pelvic abscess and abdominal-perineal fistula. Profuse exudate contaminated the midline abdominal incision through the abdominal-perineal fistula and delayed healing. Because of a residual tumor and the high cost, negative-pressure wound therapy was not performed. After 76 days of local treatment that involved removing necrotic tissue, controlling inflammation with an antimicrobial silver dressing, absorbing and draining exudate with a hypertonic saline dressing, promoting granulation and preventing infection with a silver alginate dressing, and promoting re-epithelialization with recombinant human epidermal growth factor gel, the abdominal wound and abdominal-perineal fistula healed successfully.
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Affiliation(s)
- Hui Yang
- Hui Yang, MM, is PhD Candidate, West China School of Nursing, Sichuan University, and Head Nurse, Gastrointestinal Surgery Center, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China. Yuanyi Rui, MD, is Attending Physician, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China. Hong Chen, MD, is Professor and Doctoral Supervisor, West China School of Nursing, Sichuan University. Acknowledgments : This research was supported by Sichuan Province Science and Technology Support Program (No. 2019YFS0387). The authors have disclosed no other financial relationships related to this article. Submitted March 16, 2021; accepted in revised form July 12, 2021
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19
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van Rees JM, Visser E, van Vugt JLA, Rothbarth J, Verhoef C, van Verschuer VMT. Impact of nutritional status and body composition on postoperative outcomes after pelvic exenteration for locally advanced and locally recurrent rectal cancer. BJS Open 2021; 5:6406859. [PMID: 34672343 PMCID: PMC8529522 DOI: 10.1093/bjsopen/zrab096] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/22/2021] [Indexed: 12/29/2022] Open
Abstract
Background Pelvic exenteration for locally advanced rectal cancer (LARC) and locally recurrent (LRRC) rectal cancer provides radical resection and local control, but is associated with considerable morbidity. The aim of this study was to determine risk factors, including nutritional status and body composition, for postoperative morbidity and survival after pelvic exenteration in patients with LARC or LRRC. Methods Patients with LARC or LRRC who underwent total or posterior pelvic exenteration in a tertiary referral centre from 2003 to 2018 were analysed retrospectively. Nutritional status was assessed using the Malnutrition Universal Screening Tool (MUST). Body composition was estimated using standard-of-care preoperative CT of the abdomen. Logistic regression analyses were performed to identify risk factors for complications with a Clavien–Dindo grade of III or higher. Risk factors for impaired overall survival were calculated using Cox proportional hazards analysis. Results In total, 227 patients who underwent total (111) or posterior (116) pelvic exenteration were analysed. Major complications (Clavien–Dindo grade at least III) occurred in 82 patients (36.1 per cent). High risk of malnutrition (MUST score 2 or higher) was the only risk factor for major complications (odds ratio 3.99, 95 per cent c.i. 1.76 to 9.02) in multivariable analysis. Mean follow-up was 44.6 months. LRRC (hazard ratio (HR) 1.61, 95 per cent c.i. 1.04 to 2.48) and lymphovascular invasion (HR 2.20, 1.38 to 3.51) were independent risk factors for impaired overall survival. Conclusion A high risk of malnutrition according to the MUST is a strong risk factor for major complications in patients with LARC or LRRC undergoing exenteration surgery.
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Affiliation(s)
- Jan M van Rees
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Eva Visser
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Jeroen L A van Vugt
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Joost Rothbarth
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Victorien M T van Verschuer
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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20
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Nishimuta M, Hamada K, Sumida Y, Araki M, Wakata K, Kugiyama T, Shibuya A, Hashimoto S, Ozeki K, Morino S, Kiya S, Baba M, Nakamura A. Long-Term Prognosis after Surgery for Locally Recurrent Rectal Cancer: A Retrospective Study. Asian Pac J Cancer Prev 2021; 22:1531-1535. [PMID: 34048182 PMCID: PMC8408410 DOI: 10.31557/apjcp.2021.22.5.1531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Indexed: 12/20/2022] Open
Abstract
Objective: Resection is usually recommended for locally recurrent rectal cancer (LRRC) for which R0 resection is possible, but its suitability varies by individual patient risk. Here, we report outcomes of resected LRRC in our hospital. Methods: We retrospectively evaluated short- and long-term results of 33 patients who underwent resections for LRRC from January 2003 to December 2019. Results: At the initial surgeries for these 33 patients, their disease stages at that time were Stage I: n=2, Stage II: n=12, Stage III: n=11, Stage IV: n=6, and unknown: n=2. Patients with Stage IV disease at their initial surgeries underwent radical one-step or two-step procedures. Metastasis to other organs was observed in 5 patients at the their initial LRRC diagnoses. At the LRRC surgeries, 7 patients received palliative surgeries; 26 received intent-to-treat resections, of which 17 were R0 resections. All-grade postoperative complications were observed in 11 patients, including 1 surgery-related death. Five-year overall survival rates were all cases: 38.4%; R0 group: 52.3%, R1 or R2 group: 19.4%, and palliative surgery group: 0%. The R0 group thus had significantly better prognosis than other patients (P = 0.0012). Eleven patients in the R0 group (64.7%) suffered re-recurrences but some patients achieved long-term survival through chemotherapy, radiation therapy, and surgery for metastasis to other organs, even after re-recurrence. Conclusion: Long-term prognosis after surgery for LRRC was significantly better for patients with R0 margins. Multimodal treatments may greatly improve survival for patients who suffer re-recurrences after local recurrence resections.
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Affiliation(s)
- Masato Nishimuta
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Kiyoaki Hamada
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Yorihisa Sumida
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Masato Araki
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Kouki Wakata
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Tota Kugiyama
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Ayako Shibuya
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Shintaro Hashimoto
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Keisuke Ozeki
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Shigeyuki Morino
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Soichiro Kiya
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Masayuki Baba
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
| | - Akihro Nakamura
- Department of Surgery, Sasebo City General Hospital, 9-3 Hirase, Sasebo, Nagasaki, Japan
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21
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Persistent High Rate of Positive Margins and Postoperative Complications After Surgery for cT4 Rectal Cancer at a National Level. Dis Colon Rectum 2021; 64:389-398. [PMID: 33651005 DOI: 10.1097/dcr.0000000000001855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND A more extensive resection is often required in locally advanced rectal cancer, depending on preoperative neoadjuvant treatment response. OBJECTIVE Circumferential margin involvement and postoperative outcomes after total mesorectal excision and multivisceral resection were assessed in patients with clinical locally advanced (cT4) rectal cancer at a national level. DESIGN This is a population-based study. SETTINGS Data were retrieved from the Dutch Colorectal Audit. PATIENTS A total of 2242 of 2881 patients with cT4 rectal cancer between January 2009 and December 2017 were selected. MAIN OUTCOME MEASURES Main outcomes were resection margins, postoperative complications, and mortality. RESULTS Multivisceral resection was performed in 936 of 2242 patients, of whom 629 underwent extended multivisceral resection. Positive circumferential margin rate was higher after multivisceral resection than after total mesorectal excision: 21.2% vs 13.9% (p < 0.001). More postoperative complications occurred after limited and extended multivisceral resections than after total mesorectal excision (44.1% and 53.8% vs 37.6%, p < 0.001). Incidence of 30-day mortality was similarly low in both groups (1.5% vs 2.2%, p = 0.20). Independent predictors of postoperative complications were age ≥70 years (OR, 1.28 [95% CI, 1.04-1.56]; p = 0.02), male sex (OR, 1.68 [95% CI, 1.38-2.04]; p< 0.001), mucinous tumors (OR, 1.55 [95% CI, 1.06-2.27]; p = 0.02), extended multivisceral resection (OR, 1.98 [95% CI, 1.56-2.52]; p< 0.001), Hartmann procedure (OR, 1.42 [95% CI, 1.07-1.90]; p = 0.02), and abdominoperineal resection (OR, 1.56 [95% CI, 1.25-1.96]; p < 0.001). LIMITATIONS Data specifying the extent of multivisceral resections and Clavien Dindo I to II complications were not available. CONCLUSIONS This population-based study revealed relatively high circumferential margin positivity and postoperative complication rates in patients with cT4 rectal cancer, especially after multivisceral resections, but low mortality rates. See Video Abstract at http://links.lww.com/DCR/B457. ALTA TASA PERSISTENTE DE MRGENES POSITIVOS Y COMPLICACIONES POSTOPERATORIAS DESPUS DE LA CIRUGA DE CNCER RECTAL CTA NIVEL NACIONAL ANTECEDENTES:A menudo se requiere una resección más extensa en el cáncer de recto localmente avanzado, según la respuesta al tratamiento neoadyuvante preoperatorio.OBJETIVO:Se evaluó la afectación del margen circunferencial y los resultados postoperatorios después de la escisión mesorrectal total y la resección multivisceral en pacientes con cáncer rectal clínico localmente avanzado (cT4) a nivel nacional.DISEÑO:Este es un estudio poblacional.ENTORNO CLINICO:Los datos se recuperaron de la Auditoría colorrectal holandesa.PACIENTES:Se seleccionaron un total de 2242 de 2881 pacientes con cáncer de recto cT4 entre enero de 2009 y diciembre de 2017.PRINCIPALES MEDIDAS DE VALORACION:Los principales resultados fueron los márgenes de resección, las complicaciones postoperatorias y la mortalidad.RESULTADOS:Se realizó resección multivisceral en 936 de 2242 pacientes, de los cuales 629 fueron sometidos a resección multivisceral extendida. La tasa de margen circunferencial positivo fue mayor después de la resección multivisceral que después de la escisión mesorrectal total: 21,2% versus a 13,9% (p <0,001). Se produjeron más complicaciones postoperatorias después de resecciones multiviscerales limitadas y extendidas en comparación con la escisión mesorrectal total (44,1% y 53,8% versus a 37,6%, p <0,001). La incidencia de mortalidad a 30 días fue igualmente baja en ambos grupos (1,5% versus a 2,2%, p = 0,20). Los predictores independientes de complicaciones posoperatorias fueron la edad ≥70 años (OR = 1,28, IC del 95% [1,04 a 1,56], p = 0,02), hombres (OR = 1,68, IC del 95% [1,38 a 2,04], p <0,001), tumores mucinosos (OR = 1,55, IC del 95% [1,06 a 2,27], p = 0,02), resección multivisceral extendida (OR = 1,98, IC del 95% [1,56 a 2,52], p <0,001), Hartmann (OR = 1,42, 95% Cl [1,07 a 1,90], p = 0,02) y resección abdominoperineal (OR 1,56, Cl 95% [1,25 a 1,96], p <0,001).LIMITACIONES:No se disponía de datos que especificaran el alcance de las resecciones multiviscerales y las complicaciones de Clavien Dindo I-II.CONCLUSIONES:Este estudio poblacional reveló tasas de complicaciones postoperatorias y positividad del margen circunferencial relativamente altas en pacientes con cáncer de recto cT4, especialmente después de resecciones multiviscerales, pero tasas de mortalidad bajas. Consulte Video Resumen en http://links.lww.com/DCR/B457.
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Tashiro J, Fujii M, Masaki Y, Yamaguchi S. Surgical outcomes of hybrid hand-assisted laparoscopic pelvic exenteration for locally advanced rectal cancer: Initial experience. Asian J Endosc Surg 2021; 14:213-222. [PMID: 32856403 DOI: 10.1111/ases.12855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/14/2020] [Accepted: 08/10/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Hybrid hand-assisted laparoscopic surgery (HALS) combines better visualization of laparoscopic surgery with the advantages of open surgery. The aim of this study was to describe important technical considerations of HALS and to assess the feasibility of hybrid HALS pelvic exenteration (PE) for primary advanced rectal cancer. METHODS From May 2012 to August 2018, we retrospectively analyzed 11 patients who underwent PE for primary advanced rectal cancer (< 10 cm from the anal verge). Patients were divided into the open PE group (n = 5) and the hybrid HALS PE group (n = 6). RESULTS There was no significant difference in patient characteristics between the two groups, and all included patients were male. Tumor invasion to adjacent organs was mostly anterior invasion. In addition, four patients (66%) in the hybrid HALS PE group and two (40%) in the open PE group received neoadjuvant therapy (P = .3). CONCLUSION Compared to open surgery, hybrid HALS has the advantages of less bleeding and less invasion, and can achieve the same results in the short-term. It was a reasonable procedure which was easy and safe dissection of internal iliac vessels and dorsal vein complex. Thus, hybrid HALS may become a useful approach for PE.
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Affiliation(s)
- Jo Tashiro
- Department of Gastrointestinal Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Manato Fujii
- Department of Surgery, Ome Municipal General Hospital, Tokyo, Japan
| | - Yukiyoshi Masaki
- Department of Surgery, Ome Municipal General Hospital, Tokyo, Japan
| | - Shigeki Yamaguchi
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, Saitama, Japan
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23
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Blake J, Koh CE, Steffens D, De Robles MS, Brown K, Lee P, Austin K, Solomon MJ. Outcomes following repeat exenteration for locally advanced pelvic malignancy. Colorectal Dis 2021; 23:646-652. [PMID: 33058495 DOI: 10.1111/codi.15402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/06/2020] [Accepted: 09/21/2020] [Indexed: 12/27/2022]
Abstract
AIM This study aims to assess surgical outcomes and survival following first, second and third pelvic exenterations for pelvic malignancy. METHOD Consecutive patients undergoing pelvic exenteration for pelvic malignancy at a quaternary referral centre from January 1994 and December 2017 were included. Demographics and surgical outcomes were compared between patients who underwent first, second and third pelvic exenterations by generalized mixed modelling with repeated measures. Survival was assessed using Cox proportional hazards models and Kaplan-Meier plots. RESULTS Of the 642 exenterations reviewed, 29 (4.5%) were second and 6 (0.9%) were third exenterations. Patients selected for repeat exenteration were more likely to have asymptomatic local recurrences detected on routine surveillance (P < 0.001). Postoperative wound complications increased with repeat exenteration (6%, 17%, 33%; P = 0.003, respectively). Additionally, postoperative length of stay increased from 27 to 38 and 48 days, respectively (P = 0.004). Median survival from first exenteration was 4.75, 5.30 and 8.14 years respectively amongst first, second and third exenteration cohorts (P = 0.849). Median survival from the most recent exenteration was 4.75 years after a first exenteration, 2.02 years after a second exenteration and 1.45 years after a third exenteration (P = 0.0546). CONCLUSION This study demonstrates that repeat exenteration for recurrent pelvic malignancy is feasible but is associated with increased complication rates and length of admission and reduced likelihood of attaining R0 margin. Moreover, these data indicate that repeat exenteration does not afford a survival advantage compared with patients having a single exenteration. These data suggest that repeat exenteration for recurrent pelvic malignancy may be of questionable therapeutic value.
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Affiliation(s)
- Joshua Blake
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Marie Shella De Robles
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kilian Brown
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter Lee
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Kirk Austin
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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24
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Fahy MR, Kelly ME, Nugent T, Hannan E, Winter DC. Lateral pelvic lymphadenectomy for low rectal cancer: a META-analysis of recurrence rates. Int J Colorectal Dis 2021; 36:551-558. [PMID: 33242114 DOI: 10.1007/s00384-020-03804-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Locoregional recurrence (LR) remains a problem for patients with lower rectal cancer despite standardized surgery and improved neoadjuvant treatment regimens. Lateral pelvic lymph node dissection (LPLND) has been routine practice for some time in the Orient/East, but other regions have concerns about morbidity. As perioperative care and surgical approaches are refined, this has been revisited for selected patients. The question as to whether LPLND improves oncological outcomes was explored here. METHODS A systematic review of patients who underwent TME with or without LPLND from 2000 to 2020 was performed. The primary endpoint was the rate of LR between the two groups. RESULTS Seven papers met the predefined search criteria in which 2000 patients underwent TME alone, while 1563 patients had TME and LPLND. The rate of LR was marginally higher with TME alone when compared with TME plus LPLND, but this result was not statistically significant (9.8 vs 9.4%, odds ratio 0.75, 95% CI 0.41-1.38, *p = 0.35). In addition, four studies reported on distant recurrence rates, with TME and LPLND showing a slight reduction in overall rates (27.3 vs 29.9%, respectively, OR 0.65, 95% CI 0.45-0.92, *p = 0.02). CONCLUSION The addition of LPLND to TME is not associated with a significantly lower risk of LR in patients who undergo surgery for lower rectal cancer.
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Affiliation(s)
- M R Fahy
- University College Dublin, Dublin, Ireland.
| | - M E Kelly
- University College Dublin, Dublin, Ireland
| | - T Nugent
- Trinity College Dublin, Dublin, Ireland
| | - E Hannan
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
| | - D C Winter
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland
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25
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Philip Sridhar R, Varghese G, John RA, Ranjan Jesudason M. An operative guide to laparoscopic dissection for total pelvic exenteration in a man with rectal cancer infiltrating the prostate and seminal vesicles - a video vignette. Colorectal Dis 2021; 23:767-768. [PMID: 33338324 DOI: 10.1111/codi.15499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 02/08/2023]
Affiliation(s)
| | - Gigi Varghese
- Department of Colorectal Surgery, Christian Medical College, Vellore, India
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26
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Chang KH, Brown KGM, Chen Lau Y, Solomon MJ. Excellent Outcomes After Extended Radical Pelvic Resection for Locally Advanced and Recurrent IBD-Associated Anorectal Cancer. Dis Colon Rectum 2021; 64:209-216. [PMID: 33315717 DOI: 10.1097/dcr.0000000000001744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Anorectal cancer arising in IBD can be challenging to manage. There is a paucity of reports describing locally advanced and recurrent anorectal cancer in this setting. OBJECTIVE This study aimed to describe patients who underwent extended radical pelvic resection for locally advanced and recurrent IBD-associated anorectal cancer. DESIGN This is a retrospective review of a prospectively maintained database of extended radical pelvic resection. SETTINGS This study was conducted at a quaternary pelvic malignancy referral center. PATIENTS All of the patients who underwent extended radical pelvic resection for IBD-associated anorectal cancer between September 1994 and September 2019 were included. MAIN OUTCOME MEASURES Demographic, operative, and oncologic outcomes were assessed. RESULTS Ten patients (1.3%) were identified of 765 (6 men; median age = 51 y). The average time from the diagnosis of IBD to cancer was 23 years. Five patients had surgery for primary cancer previously. All of the patients had previous complex abdominal and perineal surgical interventions. There were 7 adenocarcinomas and 3 squamous cell carcinomas. Nine underwent pelvic exenteration and 1 rectal resection with radical vaginectomy. The median operating time, intraoperative blood loss, and blood transfusion were 698 minutes, 1.8 L, and 4.5 units. The median hospital stay was 24 days. The operative mortality and morbidity rates were 0% and 60%. At a median follow-up of 51.3 months, 7 patients remained alive and free of cancer. LIMITATIONS This is a retrospective study of a small number of patients. CONCLUSIONS Extended radical pelvic resection offers a potential cure for locally advanced and recurrent IBD-associated anorectal cancer with acceptable operative mortality and morbidity rates. A high index of suspicion is required to achieve early diagnosis. Multiple factors need to be considered in the multimodal treatment of such complex patients. See Video Abstract at http://links.lww.com/DCR/B418. EXCELENTES RESULTADOS DESPUS DE LA RESECCIN PLVICA RADICAL EXTENDIDA POR CNCER ANORRECTAL RECURRENTE Y LOCALMENTE AVANZADA, ASOCIADA A ENFERMEDAD INFLAMATORIA INTESTINAL ANTECEDENTES:Cáncer anorrectal surgiendo de la enfermedad inflamatoria intestinal, puede ser difícil de manejar. Hay escasez de informes que describan el cáncer anorrectal localmente avanzado y recurrente en este contexto.OBJETIVO:El estudio tiene como objetivo, describir a los pacientes que se sometieron a resección pélvica radical extendida por cáncer anorrectal recurrente y localmente avanzada, asociada con enfermedad inflamatoria intestinal.DISEÑO:Esta es una revisión retrospectiva, de una base de datos mantenida prospectivamente de resección pélvica radical extendida.AJUSTES:El estudio se realizó en un centro de referencia cuaternaria en malignidad pélvica.PACIENTES:Se incluyeron a todos los pacientes sometidos a resección pélvica radical ampliada por cáncer anorrectal, asociada a enfermedad inflamatoria intestinal entre septiembre de 1994 y septiembre de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron los resultados demográficos, quirùrgicos y oncológicos.RESULTADOS:Diez pacientes (1.3%) fueron identificados de 765 (seis masculinos; mediana de edad 51 años). El tiempo promedio desde el diagnóstico de la enfermedad inflamatoria intestinal hasta el cáncer, fue de 23 años. Cinco pacientes fueron previamente sometidos a cirugía por cáncer primario. Todos los pacientes tuvieron previamente, intervenciones quirúrgicas abdominales y perineales complejas. Hubo siete adenocarcinomas y tres carcinomas de células escamosas. Nueve se sometieron a exenteración pélvica y una a resección rectal con vaginectomía radical. La mediana del tiempo de operación, pérdida de sangre intraoperatoria y transfusión sanguínea, fueron 698 minutos, 1.8 litros y 4.5 unidades respectivamente. La mediana de la estancia hospitalaria fue de 24 días. Las tasas de mortalidad y morbilidad operatoria fueron 0% y 60% respectivamente. En una mediana de seguimiento de 51,3 meses, siete pacientes permanecieron vivos y libres de cáncer.LIMITACIONES:Es un estudio retrospectivo con número pequeño de pacientes.CONCLUSIONES:La resección pélvica radical extendida, ofrece una cura potencial para el cáncer anorrectal recurrente y localmente avanzada, asociada a0 enfermedad inflamatoria intestinal y con tasas aceptables de mortalidad y morbilidad operatoria. Se requiere un alto índice de sospecha para obtener un diagnóstico temprano. Se deben considerar múltiples factores en el tratamiento multimodal de pacientes tan complejos. Consulte Video Resumen en http://links.lww.com/DCR/B418. (Traducción-Dr Fidel Ruiz Healy).
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Affiliation(s)
- Kah Hoong Chang
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Chris O'Brien Lifehouse Cancer Centre, Sydney, New South Wales, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,The Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Yee Chen Lau
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Chris O'Brien Lifehouse Cancer Centre, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Chris O'Brien Lifehouse Cancer Centre, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre, Sydney, New South Wales, Australia.,The Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
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27
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Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham‐Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angenete E, Antoniou A, Auer R, Austin KK, Aziz O, Baker RP, Bali M, Baseckas G, Bebington B, Bednarski BK, Beets GL, Berg PL, Beynon J, Biondo S, Boyle K, Bordeianou L, Bremers AB, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo‐Marulanda A, Chan KKL, Chang GJ, Chew MH, Chong PC, Christensen HK, Clouston H, Codd M, Collins D, Colquhoun A, Corr A, Coscia M, Coyne PE, Creavin B, Croner RS, Damjanovic L, Daniels IR, Davies M, Davies RJ, Delaney CP, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Duff M, Eglinton T, Enrique‐Navascues JM, Espin‐Basany E, Evans MD, Fearnhead NS, Flatmark K, Fleming F, Frizelle FA, Gallego MA, Garcia‐Granero E, Garcia‐Sabrido JL, Gentilini L, George ML, Ghouti L, Giner F, Ginther N, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Jenkins JT, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kelley SR, Keller DS, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kristensen HØ, Kroon HM, Kusters M, Lago V, Larsen SG, Larson DW, Law WL, Laurberg S, Lee PJ, Limbert M, Lydrup ML, Lyons A, Lynch AC, Mantyh C, Mathis KL, Margues CFS, Martling A, Meijerink WJHJ, Merkel S, Mehta AM, McArthur DR, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Morton JR, Mullaney TG, Negoi I, Neto JWM, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, O’Connell PR, O’Dwyer ST, Palmer G, Pappou E, Park J, Patsouras D, Pellino G, Peterson AC, Poggioli G, Proud D, Quinn M, Quyn A, Radwan RW, van Ramshorst GH, Rasheed S, Rasmussen PC, Regenbogen SE, Renehan A, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Ryan ÉJ, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu V, Selvasekar C, Shaikh I, Hellawell G, Shida D, Simpson A, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Sumrien H, Sutton PA, Swartking T, Taylor C, Tekkis PP, Teras J, Thurairaja R, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Vasquez‐Jimenez W, Verhoef C, Vizzielli G, Voogt ELK, Uehara K, Wakeman C, Warrier S, Wasmuth HH, Weber K, Weiser MR, Wheeler JMD, Wild J, Wilson M, de Wilt JHW, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, van Zoggel D, Winter DC. Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative. Colorectal Dis 2020; 22:1258-1262. [PMID: 32294308 DOI: 10.1111/codi.15064] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 03/24/2020] [Indexed: 02/08/2023]
Abstract
AIM At presentation, 15-20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection. METHOD Data from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival. RESULTS Of 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resections. The 30-day mortality rate was 1.6%, and 32% of patients had a major postoperative complication. The 5-year overall survival for patients in whom an R0 resection of both primary and metastatic disease was achieved was 54.6% compared with 20% for those with an R1/R2 resection (P = 0.006). CONCLUSION Simultaneous pelvic exenteration and liver resection is feasible, with acceptable morbidity and mortality. Simultaneous resection should only be performed where an R0 resection of both pelvic and hepatic disease is anticipated.
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Mirnezami R, Mirnezami A. Multivisceral Resection of Advanced Pelvic Tumors: From Planning to Implementation. Clin Colon Rectal Surg 2020; 33:268-278. [PMID: 32968362 DOI: 10.1055/s-0040-1713744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pelvic exenteration involves radical multivisceral resection for locally advanced and recurrent pelvic tumors. Advances in tumor staging, oncological therapies, preoperative patient optimization, surgical techniques, and critical care medicine have permitted the safe expansion of pelvic exenterative surgery at specialist units. It is now understood that in carefully selected patients, 5-year survival can exceed 60% following pelvic exenteration, and that very low mortality figures and an optimum postexenteration quality of life are possible. In the present review, we provide a contemporary summary of the current state of the art in pelvic exenterative surgery following all key phases of the treatment pipeline from patient staging and tumor assessment, to treatment planning and surgery.
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Affiliation(s)
- R Mirnezami
- Department of Colorectal Surgery, Royal Free Hospital, Hampstead, London
| | - A Mirnezami
- Division of Cancer Sciences, Cancer Research UK Centre, University of Southampton, Southampton, United Kingdom.,Southampton Complex Cancer and Exenterative Unit, University Hospital Southampton, Southampton, United Kingdom
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Konstantinidis IT, Lee B, Trisal V, Paz I, Melstrom K, Sentovich S, Lai L, Raoof M. National postoperative and oncologic outcomes after pelvic exenteration for T4b rectal cancer. J Surg Oncol 2020; 122:739-744. [PMID: 32516469 DOI: 10.1002/jso.26058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/08/2020] [Accepted: 05/22/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Studies reporting outcomes after pelvic exenteration for rectal cancer are limited. The objective of this study was to evaluate early postoperative and oncologic outcomes in a national multi-institutional cohort. METHODS Using the National Cancer Database (NCDB), which collects data from over 1500 commission on cancer (CoC)-accredited hospitals, we analyzed patients undergoing pelvic exenteration for T4b rectal adenocarcinoma. RESULTS There were 1367 pelvic exenterations performed in 552 hospitals. Median age was 60 years, the majority of patients (n = 831; 60.8%) were female. Neoadjuvant radiation was used only in 57%; 24.3% of resections had positive margins. Following exenteration, 30-day mortality rate, 90-day mortality rate, and readmission rates were: 1.8%, 4.4%, and 7.4%. Age ≥ 60 years and higher Charlson-Deyo comorbidity index were independently associated with increased 90-day mortality (P < .001). Overall survival (OS) was 50 months. After adjustment of significant covariates, negative margin status (adjusted HR, 0.6, 95% CI, 0.5-0.8; P < .001) and receipt of perioperative radiation or chemoradiation (adjusted HR, 0.5; 95% CI, 0.4-0.6; P < .001) were significantly associated with decreased risk of death. Only 71% of the patients received perioperative radiation. CONCLUSIONS Pelvic exenterations are being performed safely in Coc-accredited hospitals. However, up to one fourth of patients undergo resections with positive margins or are subject to underutilization of perioperative radiation therapy. Increased use of radiation may increase negative margin resections and improve patient outcomes.
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Affiliation(s)
| | - Byrne Lee
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Vijay Trisal
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Issac Paz
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Kurt Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Stephen Sentovich
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Lily Lai
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Factors impacting oncologic outcomes in patients undergoing surgery for locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2020. [DOI: 10.1016/j.scrs.2020.100765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Management strategies for patients with advanced rectal cancer and liver metastases using modified Delphi methodology: results from the PelvEx Collaborative. Colorectal Dis 2020; 22:1184-1188. [PMID: 32043753 DOI: 10.1111/codi.15007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 01/22/2020] [Indexed: 12/13/2022]
Abstract
AIM A total of 15-20% of patients with rectal cancer have liver metastases on presentation. The management of these patients is controversial. Heterogeneity in management strategies is considerable, with management often being dependent on local resources and available expertise. METHOD Members of the PelvEx Collaborative were invited to participate in the generation of a consensus statement on the optimal management of patients with advanced rectal cancer with liver involvement. Fifteen statements were created for topical discussion on diagnostic and management issues. Panellists were asked to vote on statements and anonymous feedback was given. A collaborative meeting was used to discuss any nuances and clarify any obscurity. Consensus was considered when > 85% agreement on a statement was achieved. RESULTS A total of 135 participants were involved in the final round of the Delphi questionnaire. Nine of the 15 statements reached consensus regarding the management of patients with advanced rectal cancer and oligometastatic liver disease. Routine use of liver MRI was not recommended for patients with locally advanced rectal cancer, unless there was concern for metastatic disease on initial computed tomography staging scan. Induction chemotherapy was advocated as first-line treatment in those with synchronous liver metastases in locally advanced rectal cancer. In the presence of symptomatic primary disease, a diverting stoma may be required to facilitate induction chemotherapy. Overall, only one-quarter of the panellists would consider simultaneous pelvic exenteration and liver resection. CONCLUSION This Delphi process highlights the diverse treatment of advanced rectal cancer with liver metastases and provides recommendations from an experienced international group regarding the multidisciplinary management approach.
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Kok END, van Veen R, Groen HC, Heerink WJ, Hoetjes NJ, van Werkhoven E, Beets GL, Aalbers AGJ, Kuhlmann KFD, Nijkamp J, Ruers TJM. Association of Image-Guided Navigation With Complete Resection Rate in Patients With Locally Advanced Primary and Recurrent Rectal Cancer: A Nonrandomized Controlled Trial. JAMA Netw Open 2020; 3:e208522. [PMID: 32639566 PMCID: PMC7344384 DOI: 10.1001/jamanetworkopen.2020.8522] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
IMPORTANCE The percentage of tumor-positive surgical resection margin rates in patients treated for locally advanced primary or recurrent rectal cancer is high. Image-guided navigation may improve complete resection rates. OBJECTIVE To ascertain whether image-guided navigation during rectal cancer resection improves complete resection rates compared with surgical procedures without navigation. DESIGN, SETTING, AND PARTICIPANTS This prospective single-center nonrandomized controlled trial was conducted at the Netherlands Cancer Institute-Antoni van Leeuwenhoek in Amsterdam, the Netherlands. The prospective or navigation cohort included adult patients with locally advanced primary or recurrent rectal cancer who underwent resection with image-guided navigation between February 1, 2016, and September 30, 2019, at the tertiary referral hospital. Clinical results of this cohort were compared with results of the historical cohort, which was composed of adult patients who received rectal cancer resection without image-guided navigation between January 1, 2009, and December 31, 2015. INTERVENTION Rectal cancer resection with image-guided navigation. MAIN OUTCOMES AND MEASURES The primary end point was the complete resection rate, measured by the amount of tumor-negative resection margin rates. Secondary outcomes were safety and usability of the system. Safety was evaluated by the number of navigation system-associated surgical adverse events. Usability was assessed from responses to a questionnaire completed by the participating surgeons after each procedure. RESULTS In total, 33 patients with locally advanced or recurrent rectal cancer were included (23 men [69.7%]; median [interquartile range] age at start of treatment, 61 [55.0-69.0] years). With image-guided navigation, a radical resection (R0) was achieved in 13 of 14 patients (92.9%; 95% CI, 66.1%-99.8%) after primary resection of locally advanced tumors and in 15 of 19 patients (78.9%; 95% CI, 54.4%-94.0%) after resection of recurrent rectal cancer. No navigation system-associated complications occurred before or during surgical procedures. In the historical cohort, 142 patients who underwent resection without image-guided navigation were included (95 men [66.9%]; median [interquartile range] age at start of treatment, 64 [55.0-70.0] years). In these patients, an R0 resection was accomplished in 85 of 101 patients (84.2%) with locally advanced rectal cancer and in 20 of 41 patients (48.8%) with recurrent rectal cancer. A significant difference was found between the navigation and historical cohorts after recurrent rectal cancer resection (21.1% vs 51.2%; P = .047). For locally advanced primary tumor resection, the difference was not significant (7.1% vs 15.8%; P = .69). Surgeons stated in completed questionnaires that the navigation system improved decisiveness and helped with tumor localization. CONCLUSIONS AND RELEVANCE Findings of this study suggest that image-guided navigation used during rectal cancer resection is safe and intuitive and may improve tumor-free resection margin rates in recurrent rectal cancer. TRIAL REGISTRATION Netherlands Trial Register Identifier: NTR7184.
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Affiliation(s)
- Esther N. D. Kok
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Ruben van Veen
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Harald C. Groen
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Wouter J. Heerink
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Nikie J. Hoetjes
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Erik van Werkhoven
- Department of Biometrics, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Geerard L. Beets
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Arend G. J. Aalbers
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Koert F. D. Kuhlmann
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Jasper Nijkamp
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Theo J. M. Ruers
- Department of Surgical Oncology, the Netherlands Cancer Institute—Antoni van Leeuwenhoek, Amsterdam, the Netherlands
- Faculty Applied Sciences, Group Nanobiophysics, Twente University, Enschede, the Netherlands
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Proctor MJ, Westwood DA, Donahoe S, Chauhan A, Lynch AC, Heriot AG, Sent-Doux K, Creagh T, Frizelle FA, Wakeman CJ. Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery. Colorectal Dis 2020; 22:562-568. [PMID: 31713965 DOI: 10.1111/codi.14909] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 10/29/2019] [Indexed: 02/08/2023]
Abstract
AIM Patients who undergo radical pelvic surgery often have problems with perineal wound healing and pelvic collections. While there is recognition of the perineal morbidity, there also remains uncertainty around the benefit of vertical rectus abdominus myocutaneous (VRAM) flaps due to the balance between primary healing and the complications associated with this form of reconstruction. This study aimed to evaluate factors associated with significant flap and donor site related complications following VRAM flap reconstruction for radical pelvic surgery. METHOD A retrospective analysis of VRAM flap related complications was undertaken from prospectively maintained databases for all patients undergoing radical pelvic surgery (2001- 2017) in two cancer centres. RESULTS In all, 154 patients were identified [median age 62 years (range 26-89 years), 80 (52%) men]. Thirty-three (21%) patients experienced significant donor or flap related complications. Major complications (Clavien-Dindo ≥ 3) related to the abdominal donor site occurred in nine (6%) patients, while those related to the flap or perineal site occurred in 28 (18%) patients. Only smoking (P = 0.003) and neoadjuvant radiotherapy (P = 0.047) were associated with the development of significant flap related complications on univariate analysis. Flap related complications resulted in a significantly longer hospital stay (P < 0.001). CONCLUSION Careful patient selection is required to balance the risks vs the benefits of VRAM flap reconstruction. Immediate VRAM reconstruction in patients undergoing radical pelvic surgery can achieve early healing and stable perineal closure; it has a low but significant morbidity. Major flap related complications are significantly associated with smoking status and neoadjuvant radiotherapy and result in a prolonged length of hospital stay.
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Affiliation(s)
- M J Proctor
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - D A Westwood
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - S Donahoe
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - A Chauhan
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - A C Lynch
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - A G Heriot
- Division of Cancer Surgery, Peter MacCullam Cancer Centre, Melbourne, Vic, Australia.,Department of Surgery, University of Melbourne, Melbourne, Vic, Australia
| | - K Sent-Doux
- Department of Plastic and Reconstructive Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - T Creagh
- Department of Plastic and Reconstructive Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - F A Frizelle
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.,University Department of Surgery, University of Otago, Christchurch, New Zealand
| | - C J Wakeman
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand.,University Department of Surgery, University of Otago, Christchurch, New Zealand
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Abstract
Gastrointestinal cancers are bordered by radiosensitive visceral organs, resulting in a narrow therapeutic window. The search for more efficacious and tolerable therapies raises the possibility that proton beam therapy's (PBT) physical and dosimetric differences from conventional therapy may be better suited to treat both primary and recurrent disease, which carries its own unique challenges. Currently, the maximal efficacy of radiation plans for primary and recurrent anorectal cancer is constrained by delivery techniques and modalities which must consider feasibility challenges and toxicity secondary to exposure of organs at risk (OARs). Studies using volumetric modulated arc therapy (VMAT) and intensity modulated radiation therapy (IMRT) demonstrate that more precise dose delivery to target volumes improves local control rates and reduces complications. By reducing the low-to-moderate radiation dose-bath to bone marrow, small and large bowel, and skin, PBT may offer an improved side-effect profile. The potential to reduce toxicity, increase patient compliance, minimize treatment breaks, and enable dose escalation or hypofractionation is appealing. In cases where prognosis is favorable, PBT may mitigate long-term morbidity such as secondary malignancies, femoral fractures, and small bowel obstruction.
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Affiliation(s)
| | - Jennifer Y Wo
- Harvard Medical School, Boston, MA, USA.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, USA
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Surgical and Survival Outcomes Following Pelvic Exenteration for Locally Advanced Primary Rectal Cancer: Results From an International Collaboration. Ann Surg 2019; 269:315-321. [PMID: 28938268 DOI: 10.1097/sla.0000000000002528] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of the study was to analyze data from an international collaboration, and ascertain prognostic indicators that inform clinical decision-making and practices regarding the role of pelvic exenteration for locally advanced primary rectal cancer (LARC). BACKGROUND With improved national screening programs fewer patients present with LARC. Despite this, select cohorts of patients require pelvic exenteration. To date, the majority of outcome data are from single-center series. METHODS Anonymized data from 14 countries on patients who had pelvic exenteration for LARC between 2004 and 2014 were accumulated. The primary endpoint was overall survival. The impact of resection margin, nodal status, bone resection, and use of neoadjuvant therapy (before exenteration) on survival was evaluated using multivariable analysis. RESULTS Of 1291 patients, 778 (60.3%) were male with a median (range) age of 63 (18-90) years; 78.1% received neoadjuvant therapy. Bone resection en bloc was performed in 8.2% of patients (n = 106), and 22.6% (n = 292) had resection combined with flap reconstruction. Negative resection margin (R0 resection) was achieved in 79.9%. The 30-day postoperative mortality was 1.5%.The median overall survival following R0, R1, and R2 resection was 43, 21, and 10 months (P < 0.001) with a 3-year survival of 56.4%, 29.6%, and 8.1%, respectively (P < 0.001); 37.8% of patients experienced one or more major complication. Neoadjuvant therapy increased the risk of 30-day morbidity (P < 0.012). Multivariable analysis identified resection margin and nodal status as significant determinants of overall survival (other than advanced age). CONCLUSIONS Attainment of negative resection margins (R0) is the key to survival. Neoadjuvant therapy may improve survival; however, it does so at the increased risk of postoperative morbidity.
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Nadiradze G, Yurttas C, Königsrainer A, Horvath P. Significance of multivisceral resections in oncologic surgery: A systematic review of the literature. World J Meta-Anal 2019; 7:269-289. [DOI: 10.13105/wjma.v7.i6.269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/07/2019] [Accepted: 06/17/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Multivisceral resections (MVR) are often necessary to reach clear resections margins but are associated with relevant morbidity and mortality. Factors associated with favorable oncologic outcomes and elevated morbidity rates are not clearly defined.
AIM To systematically review the literature on oncologic long-term outcomes and morbidity and mortality in cancer surgery a systematic review of the literature was performed.
METHODS PubMed was searched for relevant articles (published from 2000 to 2018). Retrieved abstracts were independently screened for relevance and data were extracted from selected studies by two researchers.
RESULTS Included were 37 studies with 3112 patients receiving MVR for colorectal cancer (1095 for colon cancer, 1357 for rectal cancer, and in 660 patients origin was not specified). The most common resected organs were the small intestine, bladder and reproductive organs. Median postoperative morbidity rate was 37.9% (range: 7% to 76.6%) and median postoperative mortality rate was 1.3% (range: 0% to 10%). The median conversion rate for laparoscopic MVR was 7.9% (range: 4.5% to 33%). The median blood loss was lower after laparoscopic MVR compared to the open approach (60 mL vs 638 mL). Lymph-node harvest after laparoscopic MVR was comparable. Report on survival rates was heterogeneous, but the 5-year overall-survival rate ranged from 36.7% to 90%, being worst in recurrent rectal cancer patients with a median 5-year overall survival of 23%. R0 -resection, primary disease setting and no lymph-node or lymphovascular involvement were the strongest predictors for long-term survival. The presence of true malignant adhesions was not exclusively associated with poorer prognosis.
Included were 16 studies with 1.600 patients receiving MVR for gastric cancer. The rate of morbidity ranged from 11.8% to 59.8%, and the main postoperative complications were pancreatic fistulas and pancreatitis, anastomotic leakage, cardiopulmonary events and post-operative bleedings. Total mortality was between 0% and 13.6% with an R0 -resection achieved in 38.4% to 100% of patients. Patients after R0 resection had 5-year overall survival rates of 24.1% to 37.8%.
CONCLUSION MVR provides, in a selected subset of patients, the possibility for good long-term results with acceptable morbidity rates. Unlikelihood of achieving R0 -status, lymphovascular- and lymph -node involvement, recurrent disease setting and the presence of metastatic disease should be regarded as relative contraindications for MVR.
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Affiliation(s)
- Giorgi Nadiradze
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Can Yurttas
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Alfred Königsrainer
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
| | - Philipp Horvath
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Comprehensive Cancer Center, Tübingen 72076, Germany
- National Center for Pleura and Peritoneum, Tübingen 72076, Germany
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Davis BR, Schlosser KA. Management of locally recurrent rectal cancer. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1053/j.scrs.2019.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Humphries EL, Kroon HM, Dudi-Venkata NN, Thomas ML, Moore JW, Sammour T. Short- and long-term outcomes of selective pelvic exenteration surgery in a low-volume specialized tertiary setting. ANZ J Surg 2019; 89:E226-E230. [PMID: 31067602 DOI: 10.1111/ans.15212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 03/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Most published data on pelvic exenteration comes from high-volume quaternary units, with limited data available from outside of this setting. This study reports outcomes of selective pelvic exenteration performed in a low-volume tertiary unit with multidisciplinary support. METHODS A retrospective review of consecutive patients who underwent pelvic exenteration surgery for rectal/anal carcinoma, or gynaecological malignancy at Royal Adelaide Hospital between June 2008 and September 2018. Descriptive statistics and Kaplan-Meier analysis of 5-year disease-free and overall survival for patients treated with curative intent were performed. RESULTS A total of 54 patients who underwent pelvic exenteration were included. Most patients presented with primary rectal adenocarcinoma, and posterior and total pelvic exenterations were the most common operations performed (>90%). Median total operating time was 323 min, median hospital stay was 15 days, and the readmission rate was 14.8%. The overall complication rate (per patient) was 70.4%, and the re-intervention rate was 20.4%. Thirteen percent of patients required intensive care unit-admission, and there was one postoperative death (1.9%). R0 resection margins were achieved in 81.5% of patients, with R1 and R2 margins in 13.0 and 5.6% of patients, respectively. Estimated 5-year disease-free survival was 38.8%, and 5-year overall survival was 65.7%. CONCLUSION Short- and long-term outcomes of selective pelvic exenteration surgery are acceptable in a low-volume specialized tertiary setting with suitable multidisciplinary expertise. If the required expertise is not readily available, then outside referral is recommended.
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Affiliation(s)
- Emily L Humphries
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nagendra N Dudi-Venkata
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michelle L Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - James W Moore
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Kulu Y. ASO Author Reflections: Pelvic Exenteration for Patients with Primary and Recurrent Pelvic Cancer. Ann Surg Oncol 2019; 26:1350. [PMID: 30843159 DOI: 10.1245/s10434-019-07282-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Yakup Kulu
- University of Heidelberg, Heidelberg, Germany.
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Pellino G, Biondo S, Codina Cazador A, Enríquez-Navascues JM, Espín-Basany E, Roig-Vila JV, García-Granero E. Pelvic exenterations for primary rectal cancer: Analysis from a 10-year national prospective database. World J Gastroenterol 2018; 24:5144-5153. [PMID: 30568391 PMCID: PMC6288654 DOI: 10.3748/wjg.v24.i45.5144] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 11/05/2018] [Accepted: 11/16/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To identify short-term and oncologic outcomes of pelvic exenterations (PE) for locally advanced primary rectal cancer (LAPRC) in patients included in a national prospective database. METHODS Few studies report on PE in patients with LAPRC. For this study, we included PE for LAPRC performed between 2006 and 2017, as available, from the Rectal Cancer Registry of the Spanish Association of Surgeons [Asociación Española de Cirujanos (AEC)]. Primary endpoints included procedure-associated complications, 5-year local recurrence (LR), disease-free survival (DFS) and overall survival (OS). A propensity-matched comparison with patients who underwent non-exenterative surgery for low rectal cancers was performed as a secondary endpoint. RESULTS Eight-two patients were included. The mean age was 61.8 ± 11.5 years. More than half of the patients experienced at least one complication. Surgical site infections were the most common complication (abdominal wound 18.3%, perineal closure 19.4%). Thirty-three multivisceral resections were performed, including two hepatectomies and four metastasectomies. The long-term outcomes of the 64 patients operated on before 2013 were assessed. The five-year LR was 15.6%, the distant recurrence rate was 21.9%, and OS was 67.2%, with a mean survival of 43.8 mo. R+ve resection increased LR [hazard ratio (HR) = 5.58, 95%CI: 1.04-30.07, P = 0.04]. The quality of the mesorectum was associated with DFS. Perioperative complications were independent predictors of shorter survival (HR = 3.53, 95%CI: 1.12-10.94, P = 0.03). In the propensity-matched analysis, PE was associated with better quality of the specimen and tended to achieve lower LR with similar OS. CONCLUSION PE is an extensive procedure, justified if disease-free margins can be obtained. Further studies should define indications, accreditation policy, and quality of life in LAPRC.
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Affiliation(s)
- Gianluca Pellino
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia 46026, Spain
| | - Sebastiano Biondo
- Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona and IDIBELL, L’Hospitalet de Llobregat, Barcelona 08907, Spain
| | - Antonio Codina Cazador
- Department of General and Digestive Surgery--Colorectal Unit, Josep Trueta University Hospital, Girona 17001, Spain
| | | | - Eloy Espín-Basany
- Department of General Surgery, Colorectal Surgery Unit, Hospital Valle de Hebron, Autonomous University of Barcelona, Barcelona 08035, Spain
| | | | - Eduardo García-Granero
- Colorectal Unit, Hospital Universitario y Politecnico La Fe, University of Valencia, Valencia 46026, Spain
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Kulu Y, Mehrabi A, Khajeh E, Klose J, Greenwood J, Hackert T, Büchler MW, Ulrich A. Promising Long-Term Outcomes After Pelvic Exenteration. Ann Surg Oncol 2018; 26:1340-1349. [PMID: 30519763 DOI: 10.1245/s10434-018-07090-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pelvic exenteration (PE) is a complex and challenging surgical procedure. The reported results of this procedure for primary and recurrent disease are limited and conflicting. METHODS This study analyzed patient outcomes after all PEs performed in the authors' department between October 2001 and December 2016. Relevant patient data were obtained from a prospective database. Morbidity and mortality were reported for all patients. For patients with malignant disease, differences in perioperative outcomes, prognostic indicators for overall survival, and local and systemic disease recurrence were analyzed using uni- and multivariate analyses. RESULTS The study enrolled 187 patients. Of the 183 patients with malignant disease, 63 (38.2%) had primary locally advanced tumors and 115 (62.5%) had recurrent tumors. The 10-year overall survival rate was 63.5% for the patients with primary tumors that were curatively resected and 20.9% for the patients with recurrent disease (p = 0.02). The 10-year survival rate for the patients with extrapelvic disease who underwent curative resection was 37%. Multivariable analysis identified margin positivity (p < 0.01), surgery lasting longer than 7 h (p = 0.02), and recurrent disease (p < 0.01) as predictors of poor survival. Multivariate analysis of local and systemic disease recurrence showed recurrent disease (p < 0.01) as the only significant prognostic factor. CONCLUSIONS Pelvic exenteration has good long-term results, even for patients with extrapelvic disease. The oncologic outcome for patients with recurrent disease is worse than for patients with primary disease. However, even for these patients, long-time survival is possible.
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Affiliation(s)
- Yakup Kulu
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Elias Khajeh
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Johannes Klose
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Johanna Greenwood
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral, and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexis Ulrich
- Chirurgische Klinik I, Lukaskrankenhaus Neuss, Neuss, Germany
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Platt E, Dovell G, Smolarek S. Systematic review of outcomes following pelvic exenteration for the treatment of primary and recurrent locally advanced rectal cancer. Tech Coloproctol 2018; 22:835-845. [PMID: 30506497 DOI: 10.1007/s10151-018-1883-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 11/13/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pelvic exenteration represents the best treatment option for cure of locally advanced or recurrent rectal cancer. This systematic review sought to evaluate current literature regarding short and long term treatment outcomes and long term survival following pelvic exenteration. METHODS A systematic search of the MEDLINE, PubMed and Ovid databases was conducted to identify suitable articles published between 2001 and 2016. The article search was performed in line with Cochrane methodology and reported according to the Preferred Reporting Items for Systematic reviews and Meta-analyses statement. RESULTS Sixteen studies were included in the final analysis, incorporating 1016 patients. Sixty-three percent of patients were male and median patient age was 59 years. Median operating time was 7.2 h with median blood loss of 1.9 l. Median postoperative stay was 17 days with a median 30-day mortality of 0. Complication rates were 31.6-86% with a return to theatre rate of 14.6%. Median R0 resection rate was 74% and was higher for primary cancer (82.6% versus 58% for recurrent cancer). Mean overall survival was 31 months and median 5-year survival was 32%. Recurrently identified indicators of adverse outcome included R1/2 resection, preoperative pelvic pain and previous abdominoperineal resection of the rectum. CONCLUSIONS Pelvic exenteration remains a major operation associated with significant morbidity and mortality. Despite advances in preoperative assessment and staging, R1 resection rates remain high. There is also a high degree of variability of reporting outcomes and standardisation of this process would aid comparison of results between centres and drive forward research in this area.
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Affiliation(s)
- E Platt
- Colorectal Unit, Derriford Hospital, Plymouth Hospital NHS Trust, Plymouth, UK.
| | - G Dovell
- Colorectal Unit, Derriford Hospital, Plymouth Hospital NHS Trust, Plymouth, UK
| | - S Smolarek
- Colorectal Unit, Derriford Hospital, Plymouth Hospital NHS Trust, Plymouth, UK
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Transperineal retropubic approach in total pelvic exenteration for advanced and recurrent colorectal and anal cancer involving the penile base: technique and outcomes. Tech Coloproctol 2018; 22:663-671. [PMID: 30306276 DOI: 10.1007/s10151-018-1852-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/08/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Complete pathological resection of locally advanced and recurrent anorectal cancer is considered the most important determinant of survival outcome. Involvement of the retropubic space with cancer threatening or involving the penile base poses specific challenges due to the potential for margin involvement and blood loss from the dorsal venous plexus. In the present study we evaluate a new transperineal surgical approach to excision of anterior compartment organs involved or threatened by cancer which facilitates exposure and visualisation of the bulbar urethra and the deep vein of the penis caudal to the retropubic space and penile base. METHODS A retrospective study was performed on male patients with tumour extension into the penile base treated at our institution using the transperineal surgical approach. Descriptive data for patient demographics, radiology, operative details, postoperative histology, complications and outcomes were collated. RESULTS Ten male patients with tumour extension into the penile base were identified. Two patients had recurrent anal cancer, 6 had locally advanced primary rectal cancer and 2 had recurrent rectal cancer. All patients had exenterative surgery with excision of the penile base utilising the transperineal approach. All patients had R0 resection. No local recurrence developed after a median follow up period of 15 months. CONCLUSIONS The transperineal approach to the penile base and retropubic space allows for high rates of R0 resection margin status with direct visualisation of the dorsal venous plexus, thereby minimising blood loss. In our experience, this technique is the preferred approach to excision of cancers threatening and involving the penile base and also for most male patients requiring total pelvic exenteration.
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Minimally invasive surgery techniques in pelvic exenteration: a systematic and meta-analysis review. Surg Endosc 2018; 32:4707-4715. [DOI: 10.1007/s00464-018-6299-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 06/18/2018] [Indexed: 12/15/2022]
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Abstract
BACKGROUND Pelvic exenteration carries significant risks of morbidity and mortality. Preoperative management is therefore crucial, and the exenteration procedure is usually performed in an elective setting. In cases of rectal cancer, however, tumor-related complications may cause a patient's condition to deteriorate rapidly, despite optimal management. Urgent pelvic exenteration then may be an option for these patients. OBJECTIVE This study aims to compare the outcomes of pelvic exenteration between the urgent and elective settings. DESIGN This is a retrospective study. SETTING This study was conducted at King Chulalongkorn Memorial Hospital between February 2006 and June 2012. PATIENTS Fifty-three patients with locally advanced rectal cancer were included. INTERVENTION All patients underwent pelvic exenteration for locally advanced rectal cancer. They were assigned to urgent and elective setting groups according to their preoperative conditions. The urgent setting group included patients who required urgent pelvic exenteration because of intestinal obstruction, bowel perforation, bleeding, or uncontrolled sepsis, despite optimal management preoperatively. MAIN OUTCOME MEASURES Twenty-six patients were classified in the urgent setting group, and 27 were classified in the elective setting group. Three-year overall and disease-free survivals were compared between the 2 groups. Thirty-day postoperative morbidity and mortality were also studied. RESULTS Three-year overall survival was 62.2% and 54.4% in the elective and urgent groups (p = 0.7), whereas three-year disease-free survival was 43% and 63.8% (p = 0.33). The median follow-up time was 33 months. Thirty-day morbidity did not differ between the 2 groups (p = 0.49). A low serum albumin level was a significant risk factor for complications. There was no postoperative mortality in this study. LIMITATIONS This was a retrospective study performed at 1 institution, and it lacked quality-of-life scores. CONCLUSION Pelvic exenteration in an urgent setting is feasible and could offer acceptable outcomes. See Video Abstract at http://links.lww.com/DCR/A591.
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Abstract
BACKGROUND Pelvic exenteration for locally recurrent rectal cancer (LRRC) is associated with variable outcomes, with the majority of data from single-centre series. This study analysed data from an international collaboration to determine robust parameters that could inform clinical decision-making. METHODS Anonymized data on patients who had pelvic exenteration for LRRC between 2004 and 2014 were accrued from 27 specialist centres. The primary endpoint was survival. The impact of resection margin, bone resection, node status and use of neoadjuvant therapy (before exenteration) was assessed. RESULTS Of 1184 patients, 614 (51·9 per cent) had neoadjuvant therapy. A clear resection margin (R0 resection) was achieved in 55·4 per cent of operations. Twenty-one patients (1·8 per cent) died within 30 days and 380 (32·1 per cent) experienced a major complication. Median overall survival was 36 months following R0 resection, 27 months after R1 resection and 16 months following R2 resection (P < 0·001). Patients who received neoadjuvant therapy had more postoperative complications (unadjusted odds ratio (OR) 1·53), readmissions (unadjusted OR 2·33) and radiological reinterventions (unadjusted OR 2·12). Three-year survival rates were 48·1 per cent, 33·9 per cent and 15 per cent respectively. Bone resection (when required) was associated with a longer median survival (36 versus 29 months; P < 0·001). Node-positive patients had a shorter median overall survival than those with node-negative disease (22 versus 29 months respectively). Multivariable analysis identified margin status and bone resection as significant determinants of long-term survival. CONCLUSION Negative margins and bone resection (where needed) were identified as the most important factors influencing overall survival. Neoadjuvant therapy before pelvic exenteration did not affect survival, but was associated with higher rates of readmission, complications and radiological reintervention.
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Multi-institutional Outcomes for Simultaneous and Staged Urinary and Fecal Diversions in Patients Without Cancer. Urology 2018; 118:202-207. [PMID: 29366642 DOI: 10.1016/j.urology.2017.11.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/19/2017] [Accepted: 11/21/2017] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To compare the morbidity and postoperative recovery between patients treated with urinary diversion after colostomy with patients undergoing simultaneous double diversion (DD). METHODS A multi-institutional retrospective review was performed in patients treated with urinary diversion after colostomy or simultaneous DD between 2007 and 2014 for noncancerous indications. The Clavien-Dindo system was used to classify complications occurring within 90 days of surgery, and high-grade adverse events (HGAE) were classified grade 3 or higher. RESULTS A total of 46 patients were identified with fecal and urinary diversions (19 in the after colostomy (AC) group, 27 in the DD group). Common indications for urinary diversion were neurogenic bladder (54%) and urinary fistula (44%). Mean hospital stay and return of bowel function after surgery for entire cohort was 13 and 7 days, respectively, with no differences between AC and DD groups. Almost 50% of patients in the cohort experienced an HGAE but there was no difference in HGAE incidence (8/19 AC, 13/27 DD; P = .69) or complication type between the groups. Increased operative time (5% risk per every 15 minutes over 7 hours, P = .03) was the only independent variable associated with increased risk of HGAE. DD was not independently associated with increased risk of HGAE compared with staged urinary diversion. CONCLUSION Morbidity and postoperative recovery appeared similar whether urinary diversion is performed after colostomy or during a DD.
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Abstract
Advanced primary and recurrent colorectal cancer can be successfully treated by experienced, dedicated centers delivering good outcomes with low mortality and morbidity. Development and implementation of a comprehensive referral pathway is to be encouraged. Multidisciplinary team management is essential in the management of this complex group of patients and is associated with significantly more complete preoperative evaluation and more accurate provision of patient information, as well as improved access to the most appropriate individualized management plan. A structured selection process can improve outcomes through standardized approaches to service delivery to provide the highest quality of care.
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Affiliation(s)
- Christos Kontovounisios
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Paris Tekkis
- Department of Colorectal Surgery, The Royal Marsden Hospital, Chelsea, London, United Kingdom.,Department of Surgery and Cancer, Imperial College, London, United Kingdom
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